THE HONORABLE FRANCES M. MURPHY, M.D., M.P.H.
DEPUTY UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
SUBCOMMITTEE ON HEALTH
HOUSE COMMITTEE ON VETERANS' AFFAIRS ON
ADVANCES IN VETERAN'S HEALTH CARE AND ASSISTANCE
TEN YEARS AFTER THE GULF WAR
January 24, 2002
Mr. Chairman, I thank you for the opportunity to testify before the subcommittee today on changes in VA health care and benefits assistance for veterans based upon ten years of experience helping Gulf War veterans. I am accompanied today by Dr. Susan Mather, VA's Chief Public Health and Environmental Hazards Officer; and Dr. Craig Hyams, VA's Chief Consultant for Occupational and Environmental Health.
The recent commemoration of the 10th anniversary of the Gulf War makes this an excellent time to reflect upon VA's responses to the needs of Gulf War veterans over the last decade. This is made all the more relevant by the recent deployment of U.S. troops in the war against terrorism. From the lessons learned in serving veterans of past conflicts, I believe that today VA is in a better position than ever before to meet the needs of veterans who serve in all capacities, both at home and abroad.
During the Gulf War, approximately 697,000 men and women served in Operations Desert Shield and Desert Storm from August 1990 to June 1991. Compared to any other military force in U.S. history, the Americans who served in the Gulf War were unique. They included more women and more parents; more members of the Reserves and National Guard were activated to serve in the Gulf. There was also greater ethnic diversity within these forces. Returning Gulf war veterans rightly expected access to high quality health care and fair compensation for injuries and illnesses resulting from the circumstances of their service.
Even before the conclusion of Operation Desert Storm, VA recognized that Gulf War veterans would likely return with unique health problems, such as respiratory illnesses from exposure to the smoke from oil fires in 1991. In 1992 and 1993 reports of increasing health problems among Gulf War veterans began to emerge. VA developed programs to respond to the unique health requirements of Gulf War veterans. In 1992 Congress authorized special health care eligibility for Gulf War veterans in Public Law 103-210. Approximately 4,500 veterans are enrolled under this special authority. To date, VA has outpatient or inpatient health care to provided nearly 300,000 Gulf War veterans.
Gulf War Veterans' Health Examination Registry
To respond to the immediate health concerns of returning Gulf War veterans, VA established a health examination registry modeled after its Agent Orange Registry program for Vietnam veterans. This Gulf War Veterans' Health Examination Registry incorporates data on symptoms, diagnoses, and reported hazardous exposures of Gulf War veterans who come to VA for this systematic clinical examination. To date, VA has evaluated more than 83,000 Gulf War veterans in this clinical registry program. VA's Registry is an important mechanism for bringing veterans into the VA health care system and for suggesting areas of research on Gulf War health questions. The insights provided by the Registry have also proven invaluable for developing appropriate outreach efforts. Operation of the registry at VA medical centers throughout the United States has produced a large cadre of physicians and other health care providers who are knowledgeable about Gulf War health care issues.
Vet Centers and Readjustment Services
VA also improved health care for Gulf War veterans by building upon existing programs. For example, VA's Vet Centers have adapted their readjustment and counseling services to help returning Gulf War veterans and their families. Authorized by Congress in 1979, VA's Vet Centers initially provided a wide range of services to Vietnam veterans, including psychotherapy, individual and family counseling, substance abuse intervention, sexual trauma counseling, and employment and educational assistance. To date, VA's Vet Centers have provided more than 115,000 Gulf War veterans with psychological war trauma counseling and other social readjustment services.
Depleted Uranium (DU) Health Surveillance Program
VA also initiated a DU Surveillance Program, originally for "friendly fire" victims who could have retained DU shrapnel in their bodies. Medically, we have nearly 50 years experience with health effects from exposure to uranium. But we have much less experience with human exposure to DU shrapnel. Published results so far indicate that the primary concern for these veterans remains the traumatic injury caused by the initial shrapnel wound rather than any subsequent health effects from DU. Nevertheless, as a matter of prudent caution, VA will continue this health surveillance program. We have also made DU exposure screening available for other Gulf War veterans. We've had about 540 requests for this 24-hour urine screen. Among those veterans given 24-hour urine tests, we've had 3 samples with elevated uranium levels, and the source of this elevation is currently under investigation.
For Gulf War veterans with severe symptoms that remain unexplained after taking a Registry health examination, the local VA physician may refer them to one of VA's four Gulf War Referral Centers. Created in 1992, the first centers were located at VA medical centers in Washington, D. C.; Houston, TX; and Los Angeles, CA. In June 1995, an additional Referral Center was designated at Birmingham, AL. The referral centers have evaluated 786 Gulf War veterans.
Environmental Hazards Centers
In 1994 VA established three Environmental Hazards Centers, in Portland, OR; East Orange, NJ; and Boston, MA. These centers developed and coordinated a broad range of Gulf War veteran health research, including epidemiological and toxicological studies. In 1996, a fourth center was added in Louisville, KY, to focus specifically on reproductive issues. In 2000, VA extended the funding of the Boston Environmental Hazards Center, and funded a new Environmental Hazards Center at the San Antonio VAMC. Funding for both centers was for five years. These joint VA and university centers bring together interdisciplinary teams of academic and VA researchers with an exceptional array of clinical and research expertise.
Clinical Demonstration Projects
In 1998 VA initiated five Clinical Demonstration Projects to test new approaches for treating and improving the health of Gulf War veterans who suffer from undiagnosed and ill-defined disabilities. These two-year projects were carried out at VA medical centers at Brockton/West Roxbury, MA; Portland/Seattle, OR; Tampa, FL; Birmingham, AL; and, Cincinnati/Cleveland, OH. Effective treatments for veterans that were developed by these programs have been made available to other VA medical centers.
Health Care Provider Education
Clinical Practice Guidelines. In response to the clinical needs of Gulf War veterans with difficult to diagnose yet sometimes debilitating symptoms, VA and the Department of Defense ( DoD) have developed new Clinical Practice Guidelines for Post-Deployment Health and for two symptom-based illnesses, Chronic Fatigue Syndrome and Fibromyalgia. These new Guidelines, which the Institute of Medicine has highly recommended, will give VA primary care providers the tools they need to diagnose and treat veterans with such illnesses.
Quarterly conference calls. VA's Environmental Agents Service conducts quarterly conference calls to ensure that the physicians and staff responsible for the Gulf War and Agent Orange Health Examination Registry programs are kept up to date on VA health care policies, new relevant statutes, and new scientific and medical care issues. Nearly one hundred medical facilities regularly participate in these calls, as do Gulf War and Agent Orange telephone hotline operators, who are at the front line of answering questions from veterans and their families.
National Conferences. Recognizing the importance of free and open discussion among scientists involved in ongoing and groundbreaking Gulf War veterans health research, VA and DoD sponsor regular research conferences on these issues. The fifth and most recent conference was held January 24 to 26, 2001, in Alexandria, VA. These conferences generate summary reports that are available to scientists, veterans, and others with an interest in veterans health issues.
Independent Study Guides. Recognizing the need to educate and train health care providers about the unique medical care needs and concerns of Gulf War veterans and veterans of other deployments, VA began an ongoing training program, known as the Veterans Health Initiative (VHI), for our health care providers. A key product of the VHI is the independent study guide "A Guide to Gulf War Veterans' Health," which will ensure that all Gulf War veterans coming to VA facilities will encounter health care providers who are knowledgeable and sensitive to their health care concerns. All VA health care providers were asked to take advantage of veterans health education programs, and the Under Secretary for Health has established performance goals to monitor compliance.
Resident Training and Pocket Cards. Because VA is extensively involved in the nationwide training of physicians, medical residents, medical students, nurses, and associated health care professionals, we are in an excellent position to affect national health care for all veterans. More than half the physicians practicing in the United States have received part of their professional education in the VA health care system. In this regard, VA has produced pocket-card guides designed to remind our health care providers about the specific health concerns of both Gulf War veterans and veterans of other eras.
To meet its goal of informing Gulf War veterans and their families about relevant health care and compensation issues, VA uses Veterans' Service Organizations (VSO) briefings, direct mailing of a quarterly Gulf War Newsletter with a distribution of over 400,000 copies, fact sheets, posters, web sites, and a national telephone helpline. From analysis of registry data, we now understand that veterans have substantial concerns about a wide range of specific exposures and experiences during the Gulf War. In response, VA has ensured that Gulf War outreach and information products provide in-depth coverage of each of these concerns.
The principal finding from VA's systematic clinical registry examinations of about 12 percent of Gulf War veterans is that veterans are suffering from a wide variety of mostly recognized illnesses that receive conventional treatments. A unique "Gulf War Syndrome" has not been identified. Subsequent research studies, some based upon initial data derived from the VA Registry, have confirmed these conclusions. These studies were summarized at the "Conference on Illnesses Among Gulf War Veterans: A Decade of Scientific Research," held January 24 to 26, 2001, in Alexandria, VA. However, despite the value of the clinical registry for improving basic health care and in generating hypotheses for further research, clinical registries are limited because participants are self-selected and exposure assessments are self-reported. Although registry findings suggest that Gulf War veterans do not have a single type of health problem, these findings cannot be used to determine whether veterans are suffering from specific diagnoses or symptoms at higher rates than expected. To determine prevalence and incidence, population-based epidemiological studies are needed.
As the lead federal agency on Gulf War related research, VA has been responsible for coordinating federally sponsored epidemiological and other relevant scientific studies. As of today, this coordinated approach has obligated approximately $174 million for 193 research projects on a very broad array of Gulf War health issues. Much of this work is still ongoing, and much of it is at non-governmental institutions, including independent research universities.
VA's own research activities include (1) the VA comprehensive mortality study; (2) an interagency study of hospitalization rates; (3) the VA National Gulf War Health Survey; and (4) longitudinal health studies currently under development that will evaluate the long term health consequences of hazardous deployments.
As a whole, the research program has focused upon specific questions related to the Gulf War. Nevertheless, there is an appreciation that the issues extend beyond this cohort of veterans and include a broad range of health effects associated with all military deployments. The lessons learned from this integrated Gulf War research program, therefore, will provide critical insights into anticipating, diagnosing, and treating the health needs of future returning veterans and their families.
National Health Survey of Gulf War Veterans and their Families
VA's National Health Survey of Gulf War Veterans and their Families is a major ongoing study initiated in recognition of the need to better characterize the health status of the entire Gulf War veteran population. Survey questionnaires were mailed to a random sample of 15,000 Gulf War veterans and an equal number of non-deployed controls. The study compared incidence rates of symptoms and illnesses and evaluated self-reported wartime exposures.
Results from the initial two phases of this study show that Gulf War veterans are reporting significantly higher rates of diverse symptoms, including joint, muscle, respiratory, gastrointestinal, and skin problems. This population also reports higher rates of chronic fatigue and symptoms of post-traumatic stress disorder (PTSD).
VA recently completed the final phase of this study, which includes a physical examination with laboratory diagnostic testing of veterans and their families. A report will be completed shortly. In this phase, 2,000 veterans and approximately 3,000 spouses and children have been thoroughly evaluated. The clinical investigation focused upon neurological and cognitive dysfunction, chronic fatigue syndrome, fibromyalgia, PTSD, arthritis, hypertension, asthma, bronchitis, and birth defects among children. This study has produced critical, objective data about the health status of a fully representative sample of Gulf War veterans and their families.
Clinical Treatment Trials
In 1998, VA and DoD initiated two clinical treatment trials called the "ABT" (antibiotic treatment) and "EBT" (exercise-behavioral therapy) trials. Gulf War veteran patients were eligible if they had at least two of three debilitating symptoms (fatigue, musculoskeletal pain, and cognitive dysfunction) that began after August 1990 and lasted for more than six months up to the present.
The ABT trial included 491 Gulf War veterans and was designed to test if antibiotic treatment with doxycycline over 12 months would improve functional status of patients with chronic symptoms. Preliminary results showed that doxycycline was not an effective treatment. The EBT trial, which included 1,092 Gulf War veterans, was designed to test if aerobic exercise and cognitive behavioral therapy ( CBT) would improve physical function in veterans. Preliminary results showed that exercise, CBT, or both did lead to significant improvements in mental health function. Moreover, exercise, with or without CBT, led to significant improvements in symptoms of fatigue and memory problems. Aerobic exercise appears to be a promising treatment for Gulf War veterans who have chronic debilitating symptoms.
Amyotrophic Lateral Sclerosis (ALS)
Gulf War veterans have voiced concerns about a possible association between ALS, also called Lou Gehrig's disease, and service in the war. Preliminary data suggested that the age distribution of cases of ALS in Gulf War veterans deployed during Operations Desert Shield/Desert Storm appeared to be younger than the age distribution of cases of ALS in the general U.S. population. In March 2000, VA began a research effort to identify all cases of ALS occurring among Gulf War veterans deployed to the Gulf during Operations Desert Shield/Desert Storm and non-deployed veterans. VA collaborated with DoD, the Centers for Disease Control and Prevention, university experts, and the ALS Association to determine the veterans' health status and to describe their exposures to potential risk factors for ALS.
The preliminary results show that Gulf War veterans deployed during Operations Desert Shield/Desert Storm had almost a two-fold increased rate of ALS, compared to non-deployed veterans. Accordingly, the Secretary of Veterans Affairs decided to take steps to compensate veterans with ALS who were deployed to the Gulf region during Operations Desert Shield/Desert Storm. VA has contacted the Gulf War veterans identified in the study to help them file new claims or to expedite existing claims. The next step in the investigation will involve careful evaluation of possible risk factors in the veterans, including family history, military occupation, injuries and trauma, and exposures to hazardous chemicals.
In 1994, in precedent-setting legislation (Public Law 103-446), Congress gave VA authority to provide service-connected compensation to certain Gulf War veterans for disabilities resulting from undiagnosed illnesses. Over 3,200 Gulf War veterans have received compensation based upon this law. More recently, in Public Law 107-103, Congress expanded this authority by further authorizing compensation for certain Gulf War veterans who are suffering from medically unexplained, chronic multisymptom illnesses that are defined by clusters of signs or symptoms. Examples of such illnesses include chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome.
To help us in establishing a sound scientific basis for compensation policy, VA contracted with the National Academy of Sciences Institute of Medicine ( IOM) to provide an independent analysis of the published peer-reviewed literature on the relevant exposures and evidence of association with health effects in Gulf War veterans. In their first report, released in September 2000, the IOM reviewed the health effects of four exposures: vaccines, depleted uranium, sarin and cyclosarin chemical warfare nerve agents, and pyridostigmine bromide chemical warfare agent pre-treatment.
On the basis of the IOM committee findings, the Secretary of Veterans Affairs determined that current scientific evidence does not support an association between these exposures and any specific disease among Gulf War veterans, and that no presumption of service connection is warranted. The IOM has already begun its next two-year review, focusing on health effects from pesticides and solvents used during the Gulf War. That report is expected to be completed in August 2002.
Veteran Health Surveillance and Outreach
Recruit Assessment Program (RAP). Based on the Department's experience with Gulf War veterans health care and benefits programs, we recognize the critical importance of good health documentation and life-long medical records that cover periods before, during, and after deployment. Many Gulf War service member and veteran health issues were not verifiable due to lack of detailed computerized records documenting pre-enlistment and pre-deployment health status. Our understanding of Gulf War veterans' illnesses is hampered by inadequate base-line health information, and inadequate documentation of health during active duty.
DoD and VA have recognized this shortcoming and are attempting, through development and implementation of the Recruit Assessment Program, to collect routine baseline health data from U.S. military recruits involved in current and future combat or peacekeeping missions. The program will establish baseline health information for use in appropriate health databases and future veterans' health, compensation, and research programs. Taken together, these efforts will help us to evaluate health problems among service-members and veterans after they leave military service and to address post-deployment health questions. This program will require the continued support of the DoD senior leadership both in concept and in application of resources. The Armed Forces Epidemiology Board and the National Academy's Institute of Medicine have also endorsed the program concept. Pilot program development and testing are under way at the Marine Corps, Navy, and Air Force recruitment and training commands.
Health Care and Surveillance following Future Combat Missions. VA and Congress have also shown an appreciation for the importance in the future of providing health care and health surveillance for veterans as soon as possible following combat missions. Section 102 of Public Law 105-368, enacted in 1998, authorizes VA to provide health care to service members who served on active duty in combat in a war after the Gulf War or during a period of hostilities after November 11, 1998, for a two-year period following their release from active service for any illness, even if there is insufficient medical evidence to conclude that such condition is attributable to such service.
This two-year period will allow for the collection of basic health information and aid in the evaluation of specific health questions, such as difficult to explain illnesses. Based upon lessons learned from the Gulf War, I believe that the continuation of this treatment authority is critical for VA's ability to provide comprehensive health care to veterans who serve in future combat missions.
Improved Clinical Care for War-Related Illnesses. Most medical care for veterans very properly focuses on well-defined conditions for which there are established treatment protocols. But our experience following the Gulf and Vietnam wars has shown us that this approach does not address the health care needs of all combat veterans. Today, we appreciate that combat casualties do not always result in visible wounds, and that historically, after all conflicts, many veterans will return with difficult to diagnose yet nevertheless debilitating health problems. This requires that we develop new ways of responding to the health needs of these veterans.
We have seen that Gulf War veterans as a whole report a variety of chronic and ill-defined symptoms including fatigue, neurocognitive problems, and musculoskeletal problems, at rates that are significantly greater than for their non-deployed peers. Such poorly understood illnesses have been reported after every major conflict since at least the U.S. Civil War, and are now being reported after recent peacekeeping missions to the Balkans. The problem of chronic and ill-defined illnesses in veterans has become a significant concern for VA, for veterans and their families, and for all Americans. Research currently indicates that for many returning veterans, the unifying health risk factor appears to be the deployment itself rather than any identifiable exposure. The insights to be gained from such research have clear implications for future VA health care, research, and compensation.
VA has responded to this issue, in part, by establishing two new national Centers for the study of war-related illnesses and post-deployment health issues. On May 9, 2001, the Secretary of Veterans Affairs approved the selection and funding of these two centers. Called Centers for the Study of War-Related Illnesses, they are located at the VA medical centers in Washington, D.C., and East Orange, NJ. A competitive, scientific, peer-review process was used to select the two sites. The centers will focus on four core areas of medical care, research, risk communication, and education for health care personnel.
We well understand that we must expect casualties with difficult to diagnose but disabling conditions from more recent deployments, such as in Bosnia and the war on terrorism. Finding effective prevention and treatment will be the primary purpose of these two new centers. Therefore, these centers will also broaden the clinical role of VA's four Gulf War Referral Centers.
The new Centers for the Study of War-Related Illnesses also have strong academic affiliations with medical schools and other health professional schools. Additionally, they are collaborating with the Department of Health and Human Services and DoD, including DoD's Centers for Deployment Health, to ensure lessons learned are applied to the active-duty military as well as to veterans.
Veterans Health Initiative. Dr Garthwaite and I have built on the lessons learned from our experience with Gulf War and Vietnam veterans programs and implemented an innovative approach to health care for veterans. The Veterans Health Initiative, is a comprehensive program to enable practitioners to recognize the connection between certain health effects and military service, to allow veterans to better document their military history, to prepare health care providers to better serve their veteran patients, and to establish a database for further study. The Education component is a voluntary program that provides continuing medical education and cash bonuses to those who successfully complete the program. Modules are being developed on Spinal Cord Injury, Cold Injuries, Traumatic Amputation, PTSD, Sensory Loss (blindness/visual impairment and hearing loss), Radiation, Agent Orange, and Gulf War. The Spinal Cord Injury, Cold Injury, Amputation, Agent Orange, and Gulf War modules have already been completed. These important tools will enable practitioners to better understand and recognize the relationship between certain health effects and military service. We look forward to expanding and enhancing this program in the near future.
Enhanced Outreach. The Gulf War made clear the value of providing timely and reliable information to veterans and their families about the health risks they faced during deployment. In this regard, VA has developed a new brochure that addresses the main health concerns for military service in Afghanistan and South Asia. It answers health-related questions that veterans, their families, and their health care providers will have about the military deployment to fight terrorism. It also describes relevant medical care programs that VA has developed in anticipation of the health needs of veterans returning from combat and peacekeeping missions abroad. The brochure will be distributed to all VA medical centers.
Interagency and International Collaboration.
Enhanced Interagency Collaboration and the Military & Veterans Health Coordinating Board (MVHCB). Work on Gulf War health issues has significantly increased intergovernmental coordination between VA, DoD, and the Department of Health and Human Services. Many in and out of government concluded that the government's response to veterans' concerns about illnesses they believed were related to their service in the Gulf War was not well coordinated among the affected Departments and agencies of the Executive Branch. The initiation in 2000 of the tri-agency Military and Veterans Health Coordinating Board has served to institutionalize future interagency cooperation. The Coordinating Board expanded the important interagency collaborative activities of the earlier Persian Gulf Veterans Health Coordinating Board to cover interagency coordination for all veteran and military deployment health issues. This formalization of governmental coordination will play a critical role in addressing health problems among veterans in future conflicts and peacekeeping missions.
International Collaboration. Increased collaboration has also extended beyond America's borders and strengthened coordination with Military and Veteran Affairs Departments and Ministries from other countries. On post-war health issues, such as those arising after the Gulf War, VA scientists and policy makers collaborate and share lessons learned with their counterparts in Canada, the United Kingdom, and Australia. Based upon the similarity of health problems among war veterans of different countries, these collaborations have begun to focus on the health questions that consistently arise among military personnel returning from all hazardous deployments.
The collective experience of caring for Gulf War veterans from the United States, Canada, the United Kingdom, and Australia also has led to a greater appreciation of the need to assist veterans with unexplained symptoms. U.S. Gulf War veterans are entitled to equitable compensation for illnesses and injuries experienced during military service or resulting from service. However, the paucity of scientific knowledge regarding the relationship between military environmental exposures and human health consequences has hindered VA's ability to establish the required nexus between Gulf War service and veterans' health problems. This difficulty was further exacerbated by the reality that some veterans have disabling multi-symptom illnesses for which no established medical diagnosis can be found.
In summary, a veteran separating from military service and seeking health care today will have the benefit of VA's decade-long experience with Gulf War health issues. VA has successfully adapted many existing programs, resulting in a clinical health registry, improved outreach and education, and readjustment counseling services for Gulf War veterans. VA has also relied on prior experience with Vietnam veterans and Agent Orange to develop a fair and defensible policy on compensation. In collaboration with other federal agencies, VA has also initiated new programs for developing and coordinating federal research on veterans' health questions.
Mr. Chairman, this concludes my statement. My colleagues and I will be happy to respond to any questions that you or other members of the subcommittee might have.